Sustainment of a youth substance use treatment model following organization-focused versus state-focused federal financing strategies: a mixed-method study

Abstract Background Sustainment of evidence-based practices (EBPs) – i.e., long-term, high-quality delivery within service systems – addressing youth substance use disorders (SUD) is often constrained by limited funding. Systems may use financing strategies to direct funds toward EBP implementation and/or sustainment, but financing strategy outcomes are rarely studied. We evaluated the sustainment of the Adolescent Community Reinforcement Approach (A-CRA), a well-established EBP for treating youth SUD, under two distinct U.S. federal financing strategies: organization-focused and state-focused grants. Method Our quasi-experimental, mixed-method study compared A-CRA sustainment between treatment organizations funded by each grant type ( n s = 78 organization-focused, 74 state-focused; from 35 states). We conducted interviews and surveys with clinicians, clinical supervisors, and state administrators up to 5 years post-grant. The sustainment outcome was a composite, organization-level measure capturing 10 key elements of A-CRA staffing, delivery, and supervision. We tested differences in sustainment by grant type and time using multilevel, mixed-effect regression, controlling for covariates (e.g., grant end-date) and conducting sensitivity analyses. We used longitudinal qualitative analysis to identify contextual factors associated with A-CRA sustainment trajectories, which we tested as moderators or mediators using quantitative measures. Results Mean scores on the 10-element A-CRA sustainment outcome were greater in organization-focused versus state-focused grants at 0–18 months post-grant (5.72 vs. 2.80; p =.007) but not at 37–60 months post-grant (5.04 vs. 3.98; p =.287); the associated grant type by time period interaction was statistically significant ( p <.001). Sensitivity analyses suggested these findings were partly explained by unmeasured state-level factors, but not by confounding temporal trends or details of SAMHSA funding history. In interviews, participants described contextual factors (e.g., leadership support, external funding) associated with A-CRA sustainment, but none of those factors were significant quantitative moderators or mediators for the effects of grant type. Discussion Organization-focused grants outperformed state-focused grants on short-term A-CRA sustainment outcomes, but by 3 years post-grant, most organizations had modest sustainment (about half of the key elements). Contextual factors were influential regardless of grant type. These findings suggest that implementation strategies for EBPs that treat youth SUD should combine direct funding for treatment organizations with broader systems-level changes that improve financial and other supports for sustainment.